Basic Information
Provider Information | |||||||||
NPI: | 1265475677 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MENNEL | ||||||||
FirstName: | ROBERT | ||||||||
MiddleName: | GARY | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 911230 | ||||||||
Address2: |   | ||||||||
City: | DALLAS | ||||||||
State: | TX | ||||||||
PostalCode: | 753911230 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9729978000 | ||||||||
FaxNumber: | 9722342987 | ||||||||
Practice Location | |||||||||
Address1: | 3410 WORTH ST | ||||||||
Address2: |   | ||||||||
City: | DALLAS | ||||||||
State: | TX | ||||||||
PostalCode: | 752462003 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2143701000 | ||||||||
FaxNumber: | 2143701026 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/14/2006 | ||||||||
LastUpdateDate: | 10/26/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RX0202X | F6039 | TX | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Medical Oncology |
ID Information
ID | Type | State | Issuer | Description | 138667402 | 05 | TX |   | MEDICAID | 138667407 | 05 | TX |   | MEDICAID | 138667404 | 05 | TX |   | MEDICAID | 8R1504 | 01 | TX | BLUE CROSS OF TX | OTHER | 138667412 | 05 | TX |   | MEDICAID | 138667414 | 05 | TX |   | MEDICAID | 138667405 | 05 | TX |   | MEDICAID | 138667410 | 05 | TX |   | MEDICAID | 138667403 | 05 | TX |   | MEDICAID | 138667406 | 05 | TX |   | MEDICAID |